Epinephrine Dosing During Cardiac Arrest
For adults in cardiac arrest, give 1 mg of epinephrine IV/IO every 3-5 minutes until return of spontaneous circulation (ROSC) is achieved. 1
For pediatric patients, give 0.01 mg/kg (maximum 1 mg) IV/IO every 3-5 minutes until ROSC is achieved. 2
Adult Dosing
The standard dose is 1 mg IV/IO every 3-5 minutes during active CPR 1. Operationally, this means administering epinephrine every second cycle of CPR after the initial dose. This dosing regimen has been used consistently across all major clinical trials and remains the evidence-based standard despite ongoing debate about optimal dosing.
Key Points for Adults:
- Initial dose: 1 mg IV/IO as soon as vascular access is obtained
- Subsequent doses: 1 mg every 3-5 minutes (practically, every other CPR cycle)
- Route priority: IV/IO strongly preferred over endotracheal administration
- No maximum dose: Continue until ROSC or termination of resuscitation efforts
Timing Considerations:
For shockable rhythms (VF/pVT), prioritize rapid defibrillation first. Give epinephrine after initial defibrillation attempts with CPR are unsuccessful 1. For non-shockable rhythms (PEA/asystole), give epinephrine as soon as vascular access is established.
What the Evidence Shows:
High-dose epinephrine (>1 mg) has been extensively studied and shows no survival benefit over standard dosing 1. Similarly, more frequent dosing intervals (<3 minutes) may be potentially harmful 1. The 2025 AHA guidelines emphasize that while epinephrine consistently improves ROSC and short-term survival, evidence for improved neurologic outcomes remains limited—but ROSC is a prerequisite for any meaningful recovery 1.
Pediatric Dosing
Give 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO every 3-5 minutes, with a maximum single dose of 1 mg 2. This corresponds to switching to the adult flat dose of 1 mg at 100 kg body weight per PALS guidelines.
Key Points for Pediatrics:
- Dose: 0.01 mg/kg IV/IO (maximum 1 mg per dose)
- Concentration for IV/IO: Use 0.1 mg/mL (1:10,000 solution)
- Timing: First dose within 5 minutes of starting chest compressions 2
- Interval: Every 3-5 minutes until ROSC
- Alternative route: If no IV/IO access, may give 0.1 mg/kg (0.1 mL/kg of 1:1,000 solution) via endotracheal tube, though this is less preferred 2
Critical Timing in Pediatrics:
Early epinephrine administration is crucial. For every minute delay in epinephrine administration beyond CPR initiation, there is a significant decrease in ROSC, 24-hour survival, survival to discharge, and favorable neurologic outcome 2. Patients receiving epinephrine within 5 minutes of CPR initiation have significantly better outcomes than those receiving it later 2.
Weight-Based Dosing Transition:
While PALS guidelines recommend weight-based dosing up to 100 kg (then switching to 1 mg flat dose), real-world practice varies considerably 3. Many institutions transition to flat dosing at lower weights (50-80 kg), though this deviates from guideline recommendations. For obese patients, consider using ideal body weight for dose calculations, though this practice varies by institution 3.
Common Pitfalls to Avoid
Delaying epinephrine for defibrillation in shockable rhythms: While defibrillation takes priority, don't withhold epinephrine indefinitely. Give it after initial unsuccessful defibrillation attempts 1.
Using high-dose epinephrine: Multiple studies confirm no benefit and potential harm from doses exceeding 1 mg in adults 1.
Endotracheal administration when IV/IO available: IV/IO routes are strongly preferred and more effective 2.
Delaying first pediatric dose beyond 5 minutes: This significantly worsens outcomes 2.
Dosing too frequently (<3 minutes): This may be harmful without providing benefit 1, 4.
Algorithm Summary
Adults:
- Obtain IV/IO access immediately
- Non-shockable rhythm → Give 1 mg epinephrine immediately
- Shockable rhythm → Defibrillate first, then 1 mg epinephrine if unsuccessful
- Repeat 1 mg every 3-5 minutes until ROSC
Pediatrics:
- Obtain IV/IO access immediately
- Calculate dose: 0.01 mg/kg (max 1 mg)
- Give first dose within 5 minutes of starting CPR
- Repeat every 3-5 minutes until ROSC
- If ≥100 kg, use flat dose of 1 mg